* Whereas: Colonoscopies performed by Gastroenterologists remain the gold standard for detecting cancerous and pre-cancerous polyps;

* Whereas: Patients deserve to be comfortable during a screening procedure, and a colonoscopy with propofol sedation administered by an Anesthesiologist or a Certified Registered Nurse Anesthetist is emerging as the accepted standard of practice in most geographic locations throughout the United States;

* Whereas: Fear of the procedure is one of the primary reasons that patients refuse to undergo this potentially life-saving procedure;

* Whereas: Patients must receive the best possible care in the right setting, but not at an unreasonable cost to patients, payers or the health care system;

* Therefore: The PCC hereby adopts the following Policy Statement to ensure the correct information is being shared with the pubic regarding the appropriate insurance coverage of sedation for colonoscopies:

Background

Colorectal cancer is the second leading cause of cancer deaths in the United States. It is expected to claim about 51,690 lives during 2012.(i) The majority of colorectal cancers arise from precancerous growths in the colon called polyps. Polyps are common in most adults, and become proportionally more prevalent with age. Unaddressed, polyps have the potential to become cancerous. Detecting and removing polyp growths through a screening colonoscopy with polypectomy reduces colorectal cancer deaths. (ii)

In order to prevent colorectal cancer, it’s vital to understand how to optimize the clinical and financial outcomes in terms of screening techniques, as well as the best way to pay for these procedures.

Colonoscopies

A cancer prevented is better than a cancer cured. When a patient receives a colonoscopy, it provides a life-saving opportunity to have polyps removed before they become cancerous. Since colonoscopies are the gold standard in screenings to detect and prevent colon cancer, PCC believe health plans and other insurers should continue to pay for the screening procedure itself, the anesthesia services associated with the colonoscopy, and the removal of any polyps. Fecal occult blood tests or sigmoidoscopy procedures are simply not as effective in screening against and preventing colorectal cancer.

Using the Right Sedation

Propofol anesthesia, administered by Anesthesiologists and Certified Registered Nurse Anesthetists/CRNAs, has fast become the standard of care in today's endoscopic suite. Several reputable, published studies have touted the clinical benefits of using propofol administered by Anesthesiologists/CRNAs during a colonoscopy. Advantages include more individuals agreeing to undergo a screening, increases in polyp detection rates, faster recovery times, and improvements in
patient satisfaction – among other benefits. PCC has published several issue briefs highlighting these benefits. A growing number of private and public payers recognize the value of anesthesia services in
endoscopy suites for their patients and reimburse accordingly.

Tracking Expenses

In light of rising health care costs, patients are forced to budget for unreimbursed medical expenses, including some of the procedures related to colonoscopies. Not all expenses involved in the procedure are reimbursed by the payer, which can lead to confusion and financial burden for the consumer.

Therefore, It is paramount patients determine upfront – before the procedure – the costs to them,
including deductibles, co-payments and out-of-network fees. Screening colonoscopies, for example, may generate three or more separate expenses: the gastroenterologist fee; the anesthesiologist fee; and the facility fee (e.g., hospital or ambulatory surgical center). In some cases, colonoscopies can be billed
using a different payment methodology that bundles the expenses into one global fee.

Public and private payers, along with attending providers, should proactively work with patients to ensure both the Gastroenterologist and the Anesthetist or CRNA are part of the patient’s network. Since the Gastroenterologist typically selects the anesthesia provider, he or she should disclose to the patient if the Anesthesiologist/CRNA is not in the network. The payer also should help its enrollees determine which providers are in network through up-to-date provider directories. This will allow the consumers an opportunity to change one or both providers to ensure they can use participating network providers in good standing, as well as incur the in-network rates for any costs they will have to cover in accordance with the terms of the their health plan (which are typically disclosed in the summary of benefits document).

Picking the Right Location

Everyone has an interest in making sure the costs for the colonoscopy procedure, anesthesia and any ancillary fees are reasonable. For example, the location where a colonoscopy takes place could make a big difference. As referenced above, in-network providers are always more cost effective, but using in- network facilities can also have a monetary impact on the patient’s wallet.

Unless the patient has complications, a hospital location might add unnecessary costs. Several published studies document that the cost of a colonoscopy/endoscopy procedure, including anesthesia, in an ambulatory surgical center (ASC) setting reduces overall costs. Expenses are further lowered since more complex patients with co-morbidities that traditionally have needed care in a hospital can now get this type of quality care with Gastroenterologists and Anesthetists/CRNAs in a non-hospital setting. It is estimated that over 90% of all colorectal cancer screening colonoscopies can be performed in an Ambulatory Surgical center by a trained Gastroenterologist, and an Anesthesiologist or CRNA. (iii) The facility costs associated with performing a colonoscopy/endoscopy in a hospital can be 5-10 times higher than receiving that level of care in an ASC or office-based setting.

Promoting Transparency

In an effort to promote the most effective clinical outcomes at the best price, PCC makes these observations:

1) Physicians want to provide the best possible screening for their patients to prevent colon cancer;
2) Patients should make informed decisions when deciding which screening and sedation options to select; and
3) Payers and providers have a professional responsibility to help inform patients what the costs will be for a colonoscopy before the procedure takes place – especially as it relates to any additional expenses due to out-of-network charges.

Inconsistent health plan coverage policies can wreak havoc for practicing physicians and their patients in terms of the procedures that are covered and those that are not. While attempting to cut their costs, some insurers attempt or actually deny patients the optimal clinical experience of having a colonoscopy while under the care of an anesthesiologist or CRNA administering propofol. This is counterproductive and conflicts with current evidence-based practices and simultaneously creates an artificial barrier to screening and reduces the number of patients willing to be screened.

Although the majority of anesthesia personnel are networked providers, the fact that this is not always the case is a real concern and becomes a financial exposure point for consumers. If they find that the Gastroenterologist and Anesthesiologist are not within the same network, patients deserve the chance to be notified ahead-of-time to empower them to use only the payer’s credentialed and participating providers, who have agreed ahead of time to charge the contracted and published fees.